Pelvic Organ Prolapse Primer

Important note: DO NOT GOOGLE IMAGE SEARCH "PROLAPSE." You will only find worst-case scenarios and it will freak you the F out if you have recently been diagnosed with prolapse. Just trust me on this one.

Pelvic organ prolapse is a difficult subject to find information about. Moms commonly talk about their achy backs, pain in the early days of breastfeeding, or even joke about peeing while jumping (common but NOT normal!), but hardly anyone talks about prolapse. For many women, this is an embarrassing topic. And that's a shame, because prolapse is probably more common than you realize. We don't know what the true incidence of prolapse is, but chances are you know someone affected by it. You might even have a mild prolapse, but no symptoms.

If you're new here, you might not know that I have a mild prolapse and have gone through pelvic floor physical therapy, so this is a topic that's near and dear to my heart.

So let's start with the basics.

What is pelvic organ prolapse?

Pelvic Organ Prolapse occurs when one or more of your pelvic organs (uterus, bladder, rectum) is no longer fully supported by your pelvic floor muscles and the fascia (layers of connective tissue), and begins to descend. The vaginal wall starts to droop inward and, in severe cases, might protrude outside the opening of the vagina. 

Types of Prolapse

There are four basic categories of pelvic organ prolapse. I've adapted these definitions from Voices for PFD; see their page for more information. As you are reading these descriptions, it might be helpful to open a separate tab to the ACOG website, where you will find animations of the various types of prolapse (this is safe for work).

 Normal pelvis

Normal pelvis

Anterior Vaginal Wall Prolapse

 Cystocele (anterior vaginall wall prolapse)

Cystocele (anterior vaginall wall prolapse)

Anterior wall prolapses include Cystocele (bladder) and Urethrocele (urethra). Anterior means "front," so these prolapses affect the front vaginal wall (closer to your pubic bone than your tailbone). Cystocele and urethrocele can often occur together, and happen when the fascia (supportive tissue) of the bladder stretches or detaches from where it's connected to the pubic bone. The bladder falls down into the vagina, causing a bulge, loss of bladder control/stress urinary incontinence, feelings of heaviness, fullness, or achiness, or feeling like you're sitting on a ball.

Posterior Vaginal Wall Prolapse

 Rectocele (posterior vaginal wall prolapse)

Rectocele (posterior vaginal wall prolapse)

If anterior means "front," then posterior means, you guessed it, "back." Posterior vaginal wall prolapses include rectocele (rectum) and enterocele (intestines), and happen when the supportive tissue between the vagina and rectum stretch or detach. The rectum or intestines then bulge or descend into the vagina. Symptoms include a bulging sensation and straining during bowel movements or feeling like you're not able to completely empty the bowels.

Uterine Prolapse

Uterine prolapse. This is a grade 4 prolapse, which means the uterus is now outside of the vaginal opening.
Uterine prolapse. This is a grade 4 prolapse, which means the uterus is now outside of the vaginal opening.

A uterine prolapse is when the uterus moves down into the vagina. In severe cases, the cervix can protrude outside the vaginal opening. Feelings of pelvic pressure or bulging are very common if you have a uterine prolapse. If the uterus and cervix are low enough, the cervix might rub on your underwear, causing bleeding and irritation.

Rectal Prolapse

Unlike the other types of prolapse, a rectal prolapse does not affect the vaginal walls. This type of prolapse is less common and occurs when the rectum's supporting structures stretch or detach, causing the rectum to fall out through the anus. Symptoms include painful bowel movements, mucus or bloody discharge from the protruding tissue, and an inability to control your bowel movements. A rectal prolapse could also be mistaken for a very large hemorrhoid.

Prolapse Diagnosis and Severity

If you suspect you have a prolapse because you can either see or feel a bulge, or because you have any of the other symptoms mentioned above (especially heaviness or achiness in your pelvis; that's a big red flag), please go see a pelvic floor physical therapist! Many OB-GYNs are not well-versed in prolapse and may dismiss your symptoms as being totally normal after having a baby. THEY'RE NOT. Don't accept a shrug as an answer. Go see a pelvic floor physical therapist or a urogynecologist, as these are the two professionals who are the best suited to help with this particular condition.

To find a pelvic floor physical therapist near you, use this website or email me -- I'll help you find someone.

Prolapses are graded on a scale from 0-4. Your physical therapist or doctor will ask you to cough or gently bear down to see how far your prolapse moves, and then measure according to how close the prolapse is to your hymenal ring (just inside the vaginal opening; where your hymen is or used to be).

Grade 0: No prolapse is present.

Grade 1: Lowest part of the prolapse is more than 1cm above hymenal ring.

Grade 2: Lowest part of the prolapse is within 1cm of the hymenal ring.

Grade 3: Lowest part of the prolapse is below the hymenal ring, but the vagina has not completely prolapsed.

Grade 4: The vagina has completely prolapsed outwards.

Source: https://www.pelvicexercises.com.au

Prolapse Risk Factors

I like to talk about the risk factors for prolapse rather than saying "causes of prolapse," because you often can't say for sure what the cause was.

Ok, now you have a good understanding of the mechanics of pelvic organ prolapse: organs descend when their support weakens. But why does that happen? Why do some women get prolapse and others don't?

That's a tough question and one that can drive you insane after receiving a prolapse diagnosis. I can tell you from personal experience that after my diagnosis, I spent a long time mentally dissecting everything I did after my youngest daughter was born, trying to pinpoint what, EXACTLY, I did that caused my prolapse.

This way lies madness. Please, if you're reading this and you have a prolapse, be kind to yourself. It happened, for whatever reason, and it is entirely possible you didn't do anything to cause your prolapse. 

Risk factors include:

  • Vaginal birth (risk increases in cases of vacuum or forceps delivery)
  • Genetics: Some women are born with stronger bones, muscles, and connective tissues than others. Those with weaker connective tissues have a higher risk of POP.
  • Smoking
  • Pelvic floor injury
  • Hysterectomy
  • Surgery to treat pelvic organ prolapse (yeah, how's that for unfair)
  • Chronic constipation, straining, or coughing
  • Obesity
  • Menopause
  • Nerve and muscle diseases that contribute to the deterioration of pelvic floor strength
  • Heavy lifting and intense repetitive activity (running, CrossFit, etc)

Please note that you can have all of these things and not have POP. You can have NONE of these things and still have POP. 

Treatment

There's really only two options here: pelvic floor physical therapy or surgery. In cases of mild to moderate prolapse (read: the organ in question is not outside of your body), PT can be hugely successful in lessening or eliminating symptoms. This is the case for me. I still HAVE a prolapse, since once the structural support has been compromised it's highly unlikely that the grade will ever be reduced to zero. Most women who have had children are walking around with a grade 1 prolapse anyway with zero symptoms, so eliminating the bulge is not usually the goal of PT. You can have a grade 3 with no symptoms, or you can have a grade 1 with severe symptoms. There's not necessarily a correlation between the grade of your prolapse and your symptoms. For a wonderful post on this subject, check out Julie Wiebe's "What is the goal of prolapse rehab?"

Surgery is usually recommended in severe cases, and I would argue that PT should be included as part of this. A pelvic floor physical therapist can work with you following your surgery to help you develop better movement strategies, which increases the odds of your repair holding up. Prolapse surgery has about a 30% failure rate. Not a typo. Yeah, that's not exciting at all, which is why PT is usually the first line of defense.

In conclusion, for now

This is just an overview, and I hope it's been helpful for those of you who are searching for answers on the great, wide internet. In the next post I'm going to answer common questions about POP. Got a specific one you'd like me to answer? Email me!